Provider Demographics
NPI:1336187814
Name:POLUKHIN, ELENA L (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:ELENA
Middle Name:L
Last Name:POLUKHIN
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3006 FRANK ST
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-5501
Mailing Address - Country:US
Mailing Address - Phone:651-699-0633
Mailing Address - Fax:651-797-3592
Practice Address - Street 1:3015 UTAH AVE S
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-3671
Practice Address - Country:US
Practice Address - Phone:952-933-1121
Practice Address - Fax:952-945-9536
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45600208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN630074000Medicaid
MN2500000652Medicare ID - Type Unspecified
MN630074000Medicaid